Provider Demographics
NPI:1366168627
Name:VAN TASSELL, MARYN CATE
Entity type:Individual
Prefix:
First Name:MARYN
Middle Name:CATE
Last Name:VAN TASSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6405 OLD MAIN HILL
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84322-6405
Mailing Address - Country:US
Mailing Address - Phone:435-797-3403
Mailing Address - Fax:
Practice Address - Street 1:6405 OLD MAIN HILL
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84322-6405
Practice Address - Country:US
Practice Address - Phone:435-797-3403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTRBT-22-239322106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician